| RPT |
.|.|TIDES Depression Follow-Up Assessment||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB:
that apply):| <*Answer_4303*>|14. Risk Assessment/Management comments:| <*Answer_4305*>|15. Patient currently on antidepressant?| <*Answer_4313*>|16. Patient taking antidepressant as
directed?| <*Answer_4314*>|17. Last filled Rx:| <*Answer_4315*>|18. Any side-effects from antidepressant?| <*Answer_4316*>|19. Intensity of side-effects:| <*Answer_4317*>|20.
Side-effect(s) from antidepressant (Check all that apply):| <*Answer_4318*>|21. Antidepressant changes by provider:| <*Answer_4489*>|22. Comments on medication compliance and side-effects|
<*Answer_4319*>|23. How often does the patient drink?| <*Answer_4331*>|24. Drinks per day:| <*Answer_4334*>|25. Number of days in a month when patient has five or more drinks:|
<*Answer_4335*>|26. Does patient want alcohol treatment?| <*Answer_4336*>|27. Patient reports significant drug abuse?| <*Answer_4338*>|28. Since the last assessment, has patient felt anxious,
frightened or had panic attack(s)?| <*Answer_4340*>|29. Does the patient want a referral for anxiety/panic symptoms?| <*Answer_4341*>|30. PTSD factors (Check all that apply):|
<*Answer_4343*>|31. Referral for PTSD treatment:| <*Answer_4344*>|32. Comments regarding co-morbidity:| <*Answer_4347*>|33. Previously sent material:| <*Answer_4473*>|34. Self-Help Plan in
place?| <*Answer_4474*>|35. Is patient doing self-help activities?| <*Answer_4475*>|36. Changes in barriers to learning (Check all that apply):| <*Answer_4478*>|37. Information offered and
encouragement (Check all that apply):| <*Answer_4476*>|38. Information to be mailed (Check all that apply):| <*Answer_4477*>|39. Number of Primary Care appointments since last DCM assessment:
(If no appts between DCM assessments, or clinic cancelled appt, enter zero.)| <*Answer_4490*>|40. Number of Primary Care appointments kept: (Do not count walk-in appointments.)|
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||Today's Date:| <*Answer_4499*>|1. The patient is feeling:| <*Answer_4487*>|2. Weeks since initial TIDES assessment:|
<*Answer_4491*>|41. Has an upcoming Primary Care visit been scheduled?| <*Answer_4492*>|42. Date of next scheduled Primary Care visit:| <*Answer_4493*>|43. Number of mental health appointments
since last assessment: (If no appts between DCM assessments, or clinic cancelled appt, enter zero.)| <*Answer_4494*>|44. Number of mental health appointments kept:| <*Answer_4495*>|45. Has an
upcoming mental health visit been scheduled?| <*Answer_4496*>|46. Date of next scheduled mental health visit:| <*Answer_4497*>|47. Mental health appointment types:| <*Answer_4498*>|48.
Comments on self-help and compliance:| <*Answer_4480*>|49. Contact with family indicated?| <*Answer_4500*>|50. Family contact goals (Check all that apply):| <*Answer_4501*>|51. Has patient
consented to family contact?| <*Answer_4502*>|52. Care Manager contact since last encounter?| <*Answer_4503*>|53. Number or contacts since last patient assessment:| <*Answer_4504*>|54. Care
Manager had contact with (Check all that apply):| <*Answer_4505*>|55. Discussed with family members:| <*Answer_4506*>|56. Impact on patient's depression care?| <*Answer_4507*>|57. Future
family contact planned?| <*Answer_4508*>|58. Comments for family involvement:| <*Answer_4509*>|59. Depression Care Panel status:| <*Answer_4554*>|60. Depression follow-up in:|
<*Answer_4511*>|59. Depression Care Panel status:| <*Answer_4553*>|62. Comments for Care Manager follow-up:| <*Answer_4512*>|63. Patient questions and concerns:| <*Answer_4513*>|64. Care
Plan suggestions (Check all that apply):| <*Answer_4514*>|65. Suggested labs:| <*Answer_4515*>|66. Was case discussed with supervisory psychiatrist?| <*Answer_4516*>|67. Supervising
psychiatrist input:| <*Answer_4517*>|68. Care Manager comments:| <*Answer_4518*>|69. Patient knows no more calls are coming?| <*Answer_4519*>|70. Patient knows to continue medication(s)?|
<*Answer_4488*>|3. Most recent PHQ-9: Declined or could not do.| <*Answer_4290*>|4. Most recent PHQ-9 score:| <*Answer_4291*>|5a. Little interest or pleasure:| <*Answer_4543*>|5b. Feeling
<*Answer_4520*>|71. Relapse strategies discussed (Check all that apply):| <*Answer_4521*>|72. Suggested clinician follow-up (Check all that apply):| <*Answer_4522*>|73. Future Care Manager
follow-up (Check all that apply):| <*Answer_4523*>|74. Patient's discharge comments:| <*Answer_4524*>|75. Patient discharge discussed with mental health?| <*Answer_4525*>|76. Psychiatrist's
input on patient discharge| <*Answer_4526*>|77. Care Manager's comments on patient discharge:| <*Answer_4527*>|78. Depression diagnosis in problem list or CPT?| <*Answer_4528*>|79.
Depression diagnosis, ICD-9:| <*Answer_4529*>|80. Provider feedback to:| <*Answer_4530*>|81. Encounter type:| <*Answer_4531*>|82. Encounter length:| <*Answer_4533*>|83. Call history: The
number of attempts to reach the patient for this assessment:| <*Answer_4532*>| $~
down, depressed or hopeless:| <*Answer_4544*>|5c. Trouble falling or staying asleep; or sleeping too much:| <*Answer_4545*>|Sleep disturbance:| <*Answer_4293*>|5d. Feeling tired or having
little energy:| <*Answer_4546*>|5e. Poor appetite or overeating:| <*Answer_4547*>|Appetite disturbance:| <*Answer_4294*>|5f. Feeling bad about yourself:| <*Answer_4548*>|5g. Trouble
concentrating on things:| <*Answer_4549*>|5h. Moving or speaking slowly; or being fidgety or restless| <*Answer_4550*>|Psycho-motor disturbance:| <*Answer_4295*>|5i. Thoughts that you would
be better off dead or of hurting yourself in some way.| <*Answer_4551*>|6. Number of symptoms present:| <*Answer_4296*>|7. Major Depression Disorder trigger symptoms:| <*Answer_4297*>|8.
Symptom Difficulty: Symptoms make work/home/getting along difficult?| <*Answer_4298*>|9. Comments on depression screening:| <*Answer_4299*>|10. Suicidial ideation (Check all that apply):|
<*Answer_4300*>|11. Other risk factors for suicide (Check all that apply):| <*Answer_4301*>|12. Is the VA suicide policy initiated?| <*Answer_4302*>|13. Suicidal ideation management (Check all
|
